Although the methods used sometimes overlap with those of suicide attempts (eg, cutting the wrists with a razor blade), nonsuicidal self-injury is distinct from suicide Suicidal Behavior Suicide is death caused by an act of self-harm that is intended to be lethal. Suicidal behavior encompasses a spectrum of behavior from suicide attempt and preparatory behaviors to completed... read more because patients do not intend the acts to be lethal. Patients may specifically state a lack of intent, or the lack may be inferred by their repeated use of clearly nonlethal methods. Despite the lack of immediate lethality, long-term risk of suicide attempts and of suicide completion is increased, and thus, nonsuicidal self-injury should not be dismissed lightly.
The most common examples of nonsuicidal self-injury include
Cutting or stabbing the skin with a sharp object (eg, knife, razor blade, needle)
Burning the skin (typically with a cigarette)
Patients often injure themselves repeatedly in a single session, creating multiple lesions in the same location, typically in areas that are easily hidden but accessible (eg, forearms, front of thighs). The behavior is often repeated, resulting in extensive patterns of scarring. Patients are often preoccupied with thoughts about the injurious acts.
Nonsuicidal self-injury tends to start in early adolescence (1 General reference Nonsuicidal self-injury is a self-inflicted act that causes pain or superficial damage but is not intended to cause death. Although the methods used sometimes overlap with those of suicide attempts... read more ). Rates from general population studies are similar between men and women. The natural history is unclear, but the behavior appears to decrease after young adulthood. Prevalence is also high in criminal populations, which tend to be predominantly male.
The motivations for nonsuicidal self-injury are unclear, but self-injury may be
A way to reduce tension or negative feelings
A way to resolve interpersonal difficulties
Self-punishment for perceived faults
A plea for help
Some patients view the self-injury as a positive activity and thus tend not to seek or accept counseling.
Nonsuicidal self-injury is often accompanied by other disorders, particularly borderline personality disorder Borderline Personality Disorder (BPD) Borderline personality disorder is characterized by a pervasive pattern of instability and hypersensitivity in interpersonal relationships, instability in self-image, extreme mood fluctuations... read more , antisocial personality disorder Antisocial Personality Disorder (ASPD) Antisocial personality disorder is characterized by a pervasive pattern of disregard for consequences and for the rights of others. Diagnosis is by clinical criteria. Treatment may include cognitive-behavioral... read more , eating disorders Introduction to Eating Disorders Eating disorders involve a persistent disturbance of eating or of behavior related to eating that Alters consumption or absorption of food Significantly impairs physical health and/or psychosocial... read more , alcohol Alcohol Use Disorder and Rehabilitation Alcohol use disorder involves a pattern of alcohol use that typically includes craving and manifestations of tolerance and/or withdrawal along with adverse psychosocial consequences. Alcoholism... read more and substance use disorders Substance Use Disorders Substance use disorders involve a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant problems related to its use. Diagnosis of substance... read more , and autism Autism Spectrum Disorders Autism spectrum disorders are neurodevelopmental disorders characterized by impaired social interaction and communication, repetitive and stereotyped patterns of behavior, and uneven intellectual... read more .
Diagnosis of Nonsuicidal Self-Injury
Exclusion of suicidal behavior
Assessment of self-injury
Diagnosis of nonsuicidal self-injury must exclude suicidal behavior.
Assessment of nonsuicidal self-injury, as for suicidal behavior, is essential before treatment begins.
Facilitating discussion of the self-injury with the patient is essential to adequate assessment and helps physicians plan treatment. Physicians can facilitate such discussions by doing the following:
Validating the patient's experience by communicating that they have heard the patient and take the patient's experiences seriously
Understanding the patient's emotions (eg, confirming that the patient's emotions and actions are understandable in light of the patient's circumstances)
Assessment of nonsuicidal self-injury should include the following:
Determining what type of self-injury and how many types of self-injury the patient has inflicted
Determining how often nonsuicidal self-injury occurs and how long it has been occurring
Determining the function of nonsuicidal self-injury for the patient
Checking for coexisting psychiatric disorders
Estimating the risk of a suicide attempt
Determining how willing the patient is to participate in treatment
Treatment of Nonsuicidal Self-Injury
Certain forms of psychotherapy (eg, cognitive behavioral therapy, dialectical behavioral therapy, emotion-regulation group therapy)
Treatment of coexisting disorders
Cognitive behavioral therapy is typically done as outpatient, individual therapy, but it can also be done in groups in an inpatient setting. Improvement occurs by helping a person change the ways they respond to their automatic thoughts, and unlinking negative thought-behavior-mood patterns.
Dialectical behavioral therapy involves individual and group therapy for at least 1 year. This therapy focuses on identifying and trying to change negative thinking patterns and promoting positive changes. It aims to help patients find more appropriate ways of responding to stress (eg, to resist urges to behave self-destructively).
Emotion-regulation group therapy is done in a 14-week group setting. This therapy involves teaching patients how to increase awareness of their emotions and provides them with skills to deal with their emotions. Emotion-regulation group therapy helps patients accept negative emotions as part of life and thus not to respond to such emotions so intensely and impulsively.
No medications have been approved for the treatment of nonsuicidal self-injury. However, naltrexone and certain second-generation antipsychotics have been effective in some patients (1 Treatment reference Nonsuicidal self-injury is a self-inflicted act that causes pain or superficial damage but is not intended to cause death. Although the methods used sometimes overlap with those of suicide attempts... read more ).
Coexisting psychiatric disorders (eg, depression Depressive Disorders Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more , eating disorders Introduction to Eating Disorders Eating disorders involve a persistent disturbance of eating or of behavior related to eating that Alters consumption or absorption of food Significantly impairs physical health and/or psychosocial... read more , substance use disorders Substance Use Disorders Substance use disorders involve a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant problems related to its use. Diagnosis of substance... read more , borderline personality disorder Borderline Personality Disorder (BPD) Borderline personality disorder is characterized by a pervasive pattern of instability and hypersensitivity in interpersonal relationships, instability in self-image, extreme mood fluctuations... read more , bipolar disorder) should be treated appropriately. Patients should be referred to an appropriate clinician as needed.
Follow-up appointments should be scheduled.
1. Turner BJ, Austin SB, Chapman AL: Treating nonsuicidal self-injury: a systematic review of psychological and pharmacological interventions. Can J Psychiatry. 2014 Nov;59(11):576-85. doi: 10.1177/070674371405901103
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
Self-Injury & Recovery Resources (SIRR): This web site was launched by Cornell University in 2003 to address the emerging phenomenon of self- injury among youth and young adults and eventually produced a series of resources to educate laypeople and professionals about nonsuicidal self-injury (NSS), as well as assessment and recovery tools to assist in the treatment of NSSI.
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